19 March 2013

Healing the Hospital Hierarchy

Story originally appeared on the Opinionator

A hospital is, by its nature, the scene of constant life-or-death situations. It’s the work we nurses, doctors and other health professionals do; we chose it. The threat of harm can jazz you up or bring you down, but what it should demand, always, is the highest possible level of professionalism. Who’s at risk when that doesn’t occur?

Consider this encounter, from a few years ago. My patient, a middle-aged man scheduled for a stem-cell transplant, was having textbook symptoms of a heart attack. Serious cardiac side effects can result from the chemical used to preserve stem cells, making the transplant risky if a patient is unstable. An EKG was done, and we were waiting for a cardiologist when the oncology team came by on morning rounds.

The attending physician heard about the patient’s chest pain, then glanced at the EKG while checking his smartphone. “This does not concern me,” he said, tapping at his screen as he pushed the EKG paper aside.
This particular doctor was known for his explosive impatience. On a good day his temper simmered just below the surface. On a bad day, he openly seethed. If I asked him to delay the transplant it would be ugly for me; if I said nothing, it could be very dangerous for my patient. So I asked for a delay.
In the hallway, the doctor, in front of the rounding team, his large body twisted down to put his face close to mine, yelled, “Why?
”
This was intimidation, plain and simple. But it was also an example of a doctor’s abusing the legal, established hierarchy between doctors and nurses.

Similarly, there are also physicians who will blame the nurse when they find it inconvenient to do their jobs. The classic example of this is the doctor who reacts rudely to middle-of-the-night pages, even though, legally, the nurse must get an order even for something as ordinary as Tums.

Most people in health care understand and accept the need for clinical hierarchies. The problem is that we aren’t usually prepared for them; nor are we given protocols for resolving the inevitable tensions that arise over appropriate care. Doctors and nurses are trained differently, and our sense of priorities can conflict. When that happens, the lack of an established, neutral way of resolving such clashes works to everyone’s detriment.

This isn’t about hurt feelings or bruised egos. Modern health care is complex, highly technical and dangerous, and the lack of flexible, dynamic protocols to facilitate communication along the medical hierarchy can be deadly. Indeed, preventable medical errors kill 100,000 patients a year, or a million people a decade, wrote Rosemary Gordon and Janardan Prasad Singh in their book “Wall of Silence.”

Nurses cannot give orders, but they are considered the “final check” on all care decisions that doctors make, and we catch mistakes all the time. The most striking example from my experience: chemotherapy intended to be given intravenously was ordered with the formula for delivery to the brain. Depending on the drug, this could have been a thousandfold dosing error.

Unfortunately, there is no established way for a nurse to resolve such an error. Most docs will recognize the mistake and correct it. But if the physician won’t do that, the nurse’s only fail-safe option is to refuse to perform the order.

The harsh truth is that such intrepid nurses can easily be fired. As the physician Otis Webb Brawley wryly observes in his book “How We Do Harm”: “To throw this kind of challenge, you have to not mind being unemployed.”

The good news is that there are institutions trying to improve how nurses and doctors work together.
Some nurses reject the whole idea of doctor’s orders; they think the term makes nursing sound subservient. As a working clinical nurse, I don’t find that a practicable approach: someone has to be ultimately responsible for clinical decisions, and M.D.’s have that authority. The challenge is making the system we have work smoothly all the time.

The good news is that there are institutions trying to improve how nurses and doctors work together. One bright light in the area of interprofessional education is the University of Virginia. With the strong backing of Dorrie Fontaine, the dean of the School of Nursing, the university requires interprofessional education for its nursing and medical school curriculums. Courses, training modules and even faculty members are shared across both disciplines. Medical and nursing students are taught to respect each other’s areas of expertise and contributions to their shared mission.

One of the program’s core areas of focus is what collaboration means to doctors and nurses. Doctors believe they know what teamwork is, but for many it may mean what Tina Brashers, the lead physician for the interprofessional education program, calls the “poof factor”: “Doctors type into the computer and POOF, the order happens,” with no input from nursing needed and little knowledge of nurses’ importance to patient care. Nurses, in contrast, are more likely to define good teamwork as a relationship in which everyone’s input counts.

Let’s hope the interprofessional education model catches on; otherwise, patients will feel the lack. My patient waiting for his transplant was lucky. The cardiologist arrived on the heels of the oncologist’s temper tantrum. After an exam and a real look at the EKG, he said the patient wasn’t having a heart attack and we could safely do the transplant.

But such encounters can have latent consequences: the power differential in hospitals is such that if a doctor chews out a nurse it tends to make her less likely to speak up the next time.

Because successful health care needs to be interdependent, the silencing of nurses inevitably creates more opportunities for error. In a system that is already error-prone and enormously complicated, where health care workers are responsible not just for people’s well-being, but their lives, behavior that in any way increases dangers to patients is intolerable. When I became a nurse, that’s not the kind of harm I signed on for.

Theresa Brown, an oncology nurse, is the author of “Critical Care: A New Nurse Faces Death, Life and Everything in Between.”